The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?
You will need to use a stethoscope properly.
You can move your arm during the reading
You can apply the cuff in any manner
You will need to recalibrate the machine
The Correct Answer is D
A. You will need to use a stethoscope properly. A portable electronic blood pressure device is automatic and does not require the use of a stethoscope. The device detects oscillations in arterial pressure to provide a reading.
B. You can move your arm during the reading. Movement during the reading can interfere with accuracy and produce incorrect results. The patient should keep the arm still and at heart level.
C. You can apply the cuff in any manner. The cuff must be applied correctly—snug but not too tight, with the lower edge about 1 inch above the antecubital fossa, and the bladder of the cuff positioned over the artery—to ensure accurate readings.
D. You will need to recalibrate the machine. Electronic blood pressure devices require periodic recalibration to maintain accuracy. The patient should follow the manufacturer’s guidelines for recalibration and compare readings with a manual blood pressure check at clinic visits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report by patient that something has given way: A patient reporting a "giving way" sensation is a classic early sign of dehiscence, indicating that the wound edges are separating.
B. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature.
C. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion.
D. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.
Correct Answer is C
Explanation
A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.
B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.
C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.
D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.
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